Vasona Creek Healthcare Center

In the surveyor’s words

From the most serious findings on record at Vasona Creek Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 22, 2021

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A used face shield was stored on top of the receptionist desk; 2. A barrel containing soiled linen was overflowing; 3. There was an uncovered garbage bin near the yellow zone (observation unit); 4. Resident 30's room had an unlabeled tube feeding syringe, and resident's urinary tubing and bag were on the floor; 5. Resident 376's urinal and water pitcher were stored together and a used under pad was on the floor; 6. A cup of tea was on top of the medication cart; 7. Garbage bin outside room K was overflowing; 8. Laundry staff did not wear an apron or gown while transporting soiled linen; 9. […]

• No harm, potential for more than minimal, patternF684Nov 25, 2024

  Based on interview and record review, the facility failed to ensure treatment orders for respiratory [breathing] therapy (RT, treatment that helps individuals optimize their respiratory function, breathe more easily, and live more comfortably) was carried out as ordered for six out of six residents (Residents 3, 5, 6, 7, 8, and 9). The failure had the potential for the residents not attaining their highest practicable physical well-being, such as not being able to attend activities or carry out the activities of daily living (ADLs; such as eating, toileting, dressing, personal hygiene, etc.) due to reduced respiratory functions. Findings: 1a. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including history of COVD-19. […]

• No harm, potential for more than minimal, patternF684Oct 3, 2024

  Based on interview, observation, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 13 of 28 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) when there were multiple days for which there was no evidence of documentation that scheduled treatments were provided. This failure had the potential to compromise the residents' health, safety, and overall well-being. Findings: 1. Review of Resident 1's physician order dated 5/15/24 indicated he had an order for, [NAME] external paste (topical cream used to aid in wound healing) 40 %, apply to bilateral buttocks topically every shift. […]

• No harm, potential for more than minimal, patternF684Aug 26, 2024

  Based on interview and record review, the facility failed to ensure services were provided for three of three sampled residents (Residents 1, 2, and 3) when there were multiple days for which there was no documentation that chest percussion therapy (treatment that involves using cupped hands to tap the area over the resident's lungs to help clear secretions) was provided as ordered. This had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including pulmonary fibrosis (a condition in which the lungs become scarred) and emphysema (a condition in which damage to the air sacs in the lungs cause breathing difficulty). […]

• No harm, potential for more than minimal, patternF658Mar 13, 2024

  Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Licensed nurses did not administer a medication because it was not available in the facility; 2. The facility did not receive lab results (blood test results) and did not follow up with the lab regarding these results; 3. The facility did not administer Boost High Protein (a nutritional drink) as indicated in the admission orders; 4. Licensed nurses did not carry out an admission order for Pedialyte (a solution used to replace fluids and minerals in the body) until five days after admission; 5. The facility did not update wound treatments as ordered; and 6. […]